Case Presentation

8th Book ReviewObstestrics & Gynecology 2007313075

ContentsSymptoms & Signs of Pregnancy Naegeles rule &

Disorders of Amniotic fluidNormal amniotic fluidPolyhydramniosOligohydramnios

Signs and SymptomsCessation of mensesChanges in cervical mucusBreast ChangesVaginal mucosaSkin changesChanges in the uterusCervical changesPerception of Fetal Movements

Cessation of MensesThe abrupt cessation of menstruation in a healthy reproductive-aged woman who previously has experienced spontaneous, cyclical, predictable menses is highly suggestive of pregnancy. As discussed in Chapter 3, Interval between Menses, there is appreciable variation in the length of the ovarianand thus menstrualcycle among women, and even in the same woman. Thus, amenorrhea is not a reliable indication of pregnancy until 10 days or more after expected menses onset. When a second menstrual period is missed, the probability of pregnancy is much greater.Uterine bleeding somewhat suggestive of menstruation occurs occasionally after conception. One or two episodes of bloody discharge, somewhat reminiscent of and sometimes mistaken for menstruation, are not uncommon during the first month of pregnancy. Such episodes are interpreted to be physiological, and likely the consequence of blastocyst implantation.

Changes in Cervical MucusDried cervical mucus examined microscopically has characteristic patterns dependent on the stage of the ovarian cycle and the presence or absence of pregnancy. Mucus crystallization necessary for the production of the fern pattern is dependent on an increased sodium chloride concentration. Cervical mucus is relatively rich in sodium chloride when estrogen, but not progesterone, is being produced. Thus, from approximately the 7th to the 18th day of the cycle, a fernlike pattern is seen (Fig. 8-3).In contrast, progesterone secretioneven without a reduction in estrogen secretionacts promptly to lower sodium chloride concentration to levels that prohibit ferning. During pregnancy, progesterone usually exerts a similar effect, even though the amount of estrogen produced is enormous. After approximately the 21st day, a different pattern forms that gives a beaded or cellular appearance (Fig. 8-4). This beaded pattern also is usually encountered during pregnancy. Thus, copious thin mucus with a fern pattern on drying makes early pregnancy unlikely.

Breast ChangesAnatomical changes in the breasts that accompany pregnancy are characteristic during a first pregnancy (see Chap. 5, Breasts). These are less obvious in multiparas, whose breasts may contain a small amount of milky material or colostrum for months or even years after the birth of their last child, especially if the child was breast fed.

Vaginal MucosaDuring pregnancy, the vaginal mucosa usually appears dark bluish- or purplish-red and congestedthe Chadwick sign, popularized by him in 1886. Although presumptive evidence of pregnancy, it is not conclusive.

Skin ChangesIncreased pigmentation and changes in appearance of abdominal striae are common to, but not diagnostic of, pregnancy. They may be absent during pregnancy, and they may be seen in women taking estrogen-progestin contraceptives (see Chap. 5, Abdominal Wall and Chap. 56, Skin Changes in Pregnancy).

Changes in the UterusDuring the first few weeks of pregnancy, the increase in uterine size is limited principally to the anteroposterior diameter. By 12 weeks, the body of the uterus is almost globular with an average diameter of 8 cm. On bimanual examination, it feels doughy or elastic and sometimes becomes exceedingly soft. At 6 to 8 weeks' menstrual age, a firm cervix is felt which contrasts with the now softer fundus and compressible interposed softened isthmusthe Hegar sign. The softening at the isthmus may be so marked that the cervix and the body of the uterus seem to be separate organs.When using a stethoscope for auscultation, the uterine souffle may be heard in the later months of pregnancy. This is a soft, blowing sound that is synchronous with the maternal pulse. It is produced by the passage of blood through the dilated uterine vessels and is heard most distinctly near the lower portion of the uterus. In contrast, the funic souffle is a sharp, whistling sound that is synchronous with the fetal pulse. It is caused by the rush of blood through the umbilical arteries and may not be heard consistently.

Cervical ChangesThere is increased cervical softening as pregnancy advances. Other conditions, such as estrogenprogestin contraceptives, may also cause such softening. As pregnancy progresses, the external cervical os and cervical canal may become sufficiently patulous to admit the fingertip. However, the internal os should remain closed.

Perception of Fetal MovementsMaternal perception of fetal movement may depend on factors such as parity and habitus. In general, after a first successful pregnancy, a woman may first perceive fetal movements between 16 and 18 weeks. A primigravida may not appreciate fetal movements until approximately 2 weeks later (18 to 20 weeks). At approximately 20 weeks, depending on maternal habitus, an examiner can begin to detect fetal movements.

4Pregnancy TestsMeasurement of hCGincrease exponentially after implantation. reach peak levels at 60 to 70 days. a nadir is reached at about 16 weeks.

Sonographic Recognitiontransvaginal sonographygestational sac : GA 4 weeksnormal sac : GA 5 weeksthe crown-rump length is predictive of gestational age

Expected Date of Delivery 280 .

Naegeles Rule LMP Day : 7 Month : 9 3

LMP 4/2 : 2/18 : 11/27 : 1 911 25 8 34 9 37

Blood : Hb, Hct, PLT, RBC, ABO type Urine : Glu, Protein Ultrasonography10Prenatal Care Schedule 15~20w24~28w29~42w ,

Hb, Hct Antibody screening HIV Ab Pap smear Tri or Quad test 50g OGGT

Rhogam ** . 15~20 .50g OGGT 24~28 .Rhogam Rh(-) D- .11 ~28 : 1 / 4 weeks~36 : 1 / 2 weeks37~ :

Any vaginal bleedingSwelling of the face and fingerSevere or continuous headacheDimness or blurring of visionAbdominal painPersistent vomitingChills or feverDysuriaEscape of fluid from the vaginaMarked change in frequency or intensity of fetal movementNutritionWeight gain : about 12.5 kg9kg : , , , , , 3.5kg :

Caloriesincrease of 100 to 300 kcal per day is recommended vital role in fetal growth and developmentNutritionProteingrowth and remodeling of the fetus, placenta, uterus, and breastsamounting to 5 to 6 g/day

Iron 1000mg (300), RBC(500), (200) 7mg 30mg

NutritionFolic acidDeficiency : neural-tube defects , , 3 0.4mg 1

Common Concerns 30 : , , Ex) 38+5w

4~6 But

Common Concerns36

No problem

4 Common Concerns : GA 6~15

(Heart-burn)

(70%)

, .

Common ConcernsProgesterone

(Pica) , IDA

,

Immunization Measles, mumps, rubella, varicella : : : : , : , A, B, , , heamophilus : Tetanus, diphteria : A, B, , , , : Measles, mumps, rubella, varicellaTetanus20 Normal amniotic fluidPolyhydramniosOligohydramnios

Normal amniotic fluid36 ,

Ultrasonography Single deepest methodAmniotic fluid index

PolyhydramniosDefinitionAmniotic fluid 2000mL AFI 24~25 cm

CauseIdiopathic (2/3)Fetal malformations : CNS or GI tractGDMMultifetal gestation

PolyhydramniosDiagnosis : GA , Single pocket method :8~11cm, (80%)12~15cm, (15%)> 16cm, (5%)Amniotic fluid index 24~25 cm

Symptoms , Mirror syndrome :fetal hydrops + hydramiosmaternal edema, proteinuriaPolyhydramniosComplicationsFetus: , , , , Mather : placental abruption, uterine dysfunction, uterine atony postpartum bleeding risk

PolyhydramniosManagementMinor degrees of hydramnios rarely require treatmentAmniocentesis : dyspnea, pain Indomethacin therapy : , // ductus arteriosus

Bed rest, diuretics, and water and salt restriction are ineffective.OligohydramniosDefinitionSingle deepest 1~2cmAmniotic fluid index 5cm

CauseIdiopathic(m/c)Fetal : , , , , Placental : , Maternal : , , , Drugs : PG synthase inhibitors, ACEi

OligohydramniosPrognosisEarly-onset : 12~31% ( , )Late-onset : , APGAR score 7 , variable deceleration

Management , 20 Late-onset hydration, amnioinfusion ReferencesWilliams Obstetrics, 23rd Edition

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